Basic Information
| Provider Information | |||||||||
| NPI: | 1942399159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIEPENBROCK | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074237085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7845 CARNEGIE BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468045792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604232340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 30-022164 | OH | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | 63091 | CA | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 204E00000X | 12012587A | IN | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
No ID Information.